Provider Demographics
NPI:1396867073
Name:B. BRODEUR, JANINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JANINE
Middle Name:
Last Name:B. BRODEUR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JANINE
Other - Middle Name:MARIE
Other - Last Name:BAUMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:417 MISSION COURT
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-4018
Mailing Address - Country:US
Mailing Address - Phone:314-726-3487
Mailing Address - Fax:
Practice Address - Street 1:7396 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-4206
Practice Address - Country:US
Practice Address - Phone:314-333-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO065986163W00000X
MO1999140465103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No163W00000XNursing Service ProvidersRegistered Nurse